Compute the total cost of a health insurance plan: premium plus expected out-of-pocket given your usage.
Modeled annual cost
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Premium
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Modeled out-of-pocket
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Premium + entered OOP max
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Your breakdown
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The premium is only half of what a plan costs
People shop health insurance the way they shop a phone plan, by comparing the monthly premium and picking the cheapest. That instinct is wrong, and it can cost thousands. A low premium plan often pairs with a high deductible and high coinsurance, so the moment you actually use care, the cheap plan can become the expensive one. This calculator fixes that by computing total annual cost, the premium plus the out of pocket spending you would realistically incur given how much care you expect to use.
The model applies a simplified sequence: you pay modeled costs until the deductible, then the entered coinsurance rate applies, and covered spending is capped at the out-of-pocket maximum you enter. Real plans can use copays, separate prescription deductibles, pre-deductible services, and different network rules. The tool layers the premium on top of its estimated out-of-pocket amount to give you one comparison number, not a coverage prediction.
Why total cost beats the sticker premium
The right comparison is total expected cost equals premium plus out of pocket, where out of pocket is the smaller of two things: what you actually spend stepping through the deductible and coinsurance, or the out of pocket maximum that caps it. Whichever plan delivers the lowest total for your expected level of care is the winner, and that is frequently not the plan with the lowest premium. A healthy single person who barely sees a doctor and a family managing a chronic condition will often reach opposite conclusions from the same set of plans, which is exactly why a generic answer is useless and a personalized total is essential.
Pricing out a moderate use year
Take the editable defaults: a $6,000 annual premium, a $3,500 deductible, 20% coinsurance after the deductible, a $10,600 out-of-pocket maximum, and $5,000 of expected medical use measured at billed cost. The maximum starts at the 2026 general ACA self-only ceiling only as an example; replace every field with the figures in your plan documents.
The simplified estimate is $9,800 in this moderate-use example: $6,000 of premiums plus $3,800 of modeled cost sharing. If the entered out-of-pocket maximum is reached, the displayed premium-plus-maximum total is $16,600. That is not a cap on all health spending: premiums, noncovered services, and most out-of-network charges sit outside the ACA cost-sharing limit.
The out of pocket maximum is your floor under disaster
For plan year 2026, the general ACA maximum annual limitation on cost sharing is $10,600 for self-only coverage and $21,200 for other-than-self-only coverage. Those are federal ceilings for covered in-network essential health benefits, and a plan can set a lower maximum. Under the normal HSA-compatible HDHP test, the 2026 out-of-pocket ceiling is lower: $8,500 self-only or $17,000 family, with minimum deductibles of $1,700 or $3,400. Qualifying bronze and catastrophic individual plans available through an ACA Exchange have a current HDHP exception even when they do not meet those normal thresholds. Always enter your plan's actual maximum.
Who this is for and where to push the numbers
This is for anyone facing open enrollment with two or three plan options, through an employer or the ACA Marketplace, and no clear way to compare them. Run the same expected-use figure through each plan, then test a high-use scenario and the actual plan maximum. A high-deductible plan paired with an HSA can be attractive when premium savings, employer deposits, and eligible tax savings outweigh higher cost sharing, but that is not universal. The model treats medical use as a single billed-cost figure, while real plans apply negotiated rates, copays, prescription rules, and exclusions differently. Treat the result as a screening estimate rather than an exact prediction.
What is the difference between a deductible and an out of pocket maximum?
The deductible is what you pay before the plan starts sharing costs. The out of pocket maximum is the total ceiling on everything you pay in a year, including the deductible, coinsurance, and copays. Once you hit the maximum, the plan covers 100% of further covered, in network care. The deductible is the start of cost sharing; the maximum is the end of it.
Should I pick the lowest premium plan if I am healthy?
Not necessarily. A lower premium helps in a low-use year, but provider networks, prescription coverage, copays, employer HSA deposits, and the plan's actual cost-sharing rules can reverse the result. Run both low- and high-use scenarios, and make sure you could fund the deductible if care arrives early in the year.
Do premiums count toward my deductible or out of pocket maximum?
No. Premiums are separate. They are what you pay to have coverage at all, and they do not count toward either the deductible or the out of pocket maximum. That is exactly why comparing premiums alone is misleading, and why this calculator adds the premium to your expected out of pocket spending to show the true total.